I.

INTRODUCTION

Chronic or irreversible, renal failure is a progressive reduction of

functioning renal tissue such that the remaining kidney mass can no longermaintain the body’s internal environment. CRF can develop insidiously overmany years, or it may result from an episode of a cure renal failure from whichthe client has not recovered. The incidence of CRF varies widely by state andcountry. In the United States, the incidence is 268 new cases per millionpopulations. Chronic renal failure affects many body systems. It can also lead to manycomplications. This is the goal of health care providers, to prevent anyoccurrence of complications. One of the complications of CRF ishyperparathyroidism; this is due to the compensatory mechanism of theparathyroid hormone once it detects any alteration in the calcium level of thebody. It is important for clinicians to recognize the problem ofhyperparathyroidism early in the course of chronic kidney disease so that growthof the parathyroid glands can be prevented or halted, and excessive secretion ofhyperthyroidism can be controlled to help minimize the adverse consequenceson bone and mineral metabolism, which may lead to bone pain and bonefractures, decreased growth in children, muscle weakness, and elevations in thecalcium phosphorus product, which contributes to calcification of the heartvalves and blood vessels and contributes to the high cardiovascular mortality inpatients with advanced kidney disease. Early detection of this complication of chronic kidney disease will providean opportunity to intervene to control the secretion of parathyroid hormone and,thus, minimize the problem. Early detection will also allow for the opportunity toprevent further growth of the parathyroid glands so that the magnitude of theproblem will be lessened as kidney function deteriorates. There is also someevidence that the control of hyperparathyroidism may help to slow theprogression of kidney disease. Ultimately, it is hoped that with timely intervention

1to control this complication of chronic kidney disease, improved patient outcomeson in terms of morbidity and mortality will be achieved. To ensure that the diagnosis of hyperparathyroidism is made early in thecourse of chronic kidney disease, it is important to educate primary carephysicians, cardiologists, endocrinologists and other healthcare providers whomay see patients in the early stages of chronic kidney disease, so that they mayassess blood parathyroid hormone levels to uncover this complication and eitherembark on the treatment of hyperparathyroidism or consider referral to anephrologist for further advice on the appropriate management strategies.Referral to a nephrologist would appear to be preferable at the present time asthe field is advancing with new therapies being evaluated and implemented inpractice. At the American Society of Nephrology Renal Week 2004 meeting, resultsare being presented on the administration of oral paricalcitol, now in capsularform, so that its use can be evaluated in patients with earlier stages of kidneydisease (stage III and IV), who are not yet on dialysis. The phase 3 studies oforally administered paricalcitol showed that this strategy is effective in reducingthe degree of hyperparathyroidism, and that the administration of this vitamin Danalog is not associated with hypercalcemia, hyperphosphatemia, orhypercalcuria. Thus, the treatment was effective and well tolerated and appearedto be free of side effects. These studies are important because they provide anew therapy for the complication of hyperparathyroidism in the course chronickidney disease, and, thus, if the diagnosis of this complication can be madeearlier in the course of chronic kidney disease, treatments such as oralparicalcitol may be effective in managing this complication. As nurses, we could help our patients by having a deep understanding ofthe disease, that we may learn the proper interventions for the chronic kidneydisease patients. In this way, we could render quality care for them. We could aswell lead them to the proper treatment to lessen their sufferings brought by thekidney failure, in anyhow. By having a wide understanding of the disease, wecould impart teachings on how we could prevent the occurrence of chronic

2kidney disease. As nurses, it is our responsibility to render information and imparthealth teachings to improve the condition of our patients to the best of ourabilities. One of the characteristics that we, nurses, should have is to beinformative and only through a keen study of disease such as this way for us togain all the information that we need to learn. May this case study served itspurpose through the help of our Lord, Jesus Christ.

II. NURSING ASSESSMENT

A. Personal Data and History (Demographic Data)

Mr. x is a 53-year-old male, married living at x. He was born on September

16, 1952 in Laguna. He is married for 29 years now and has six children. He wasnot able to finished his desired career during his college years because theirfamily business was suddenly went bankrupt. According to Mr. x, education isimportant that’s why he decided to look for more affordable career. Whilestudying he decided to work to be able to support his education. With hisperseverance and determination, he was able to finished aircraft maintenance.But with all of this stress and difficulties happening in his life, he learned how tosmoke. According to him, smoking helps him to be relaxed. He consumed 8sticks/day. He was also an occasional drinker. He worked as aircraftmaintenance in Clark Air Base in Pampanga for more than 20 years. Mr. x said that he is fond of eating meat and poultry products. After work,he only stays at home because he feels very tired after work. At present, he stillworks as aircraft maintenance in Clark Air Base in Pampanga. Mr. x was admitted in x last February 3, 2005. He was admitted due tobody weakness and severe anemia. He was discharged on February 10, 2005.

3 B. Family Health-Illness History

Mother Side Father Side

Lola (+) Lolo Lola Lolo (+) D HPN

Mo Po ma p

Mr. x (+) HPN (+)Kidney Failure

C. History of Past Illness

Mr. x was known for being hypertensive for 5 years now. He wasdiagnosed of hypertension and kidney failure last x. He was hospitalized in St.Luke’s Hospital because of the said health problem. According to him, his chiefcomplain that time was only hypertension. He was discharged from the hospitalafter six days of confinement. After his discharge, Mr. x consistently having hisblood chemistry and creatinine check-up every month in AUFMC. If the resultsare all normal, his check-up becomes every month. These all became routine onhim.

On May 2004, he was hospitalized for the second time in AUFMC. Aftertwo days of confinement in the hospital, he decided to transfer in St. Luke’sHospital. Mr. Bean experienced difficulty of breathing and fatigability that time.He was diagnosed of Pulmonary Congestion.

4D. History of Present Illness

Four days prior to admission, Mr. x experienced easy fatigability. No other

accompanying signs and symptoms. His condition was persisted until one dayprior to admission, he already experiencing body weakness, body malaise, pallorand fatigability that’s why he consulted AUFMC. He was advised to havelaboratory examination (Hgb and Hct), which revealed anemia and he wasadvised to be admitted. His initial vital signs were as follows: T-36.8, RR- 22, PR-64, BP- 170/100.

2. Ordered: This is usually HBSAG- non-reactive Result

Hepatitis 2/3/05 done before ANTI-HCV- non- revealedProfile proceeding in reactive that the Performe hemodialysis. ANTI-HBC- non- patient has d: This is to reactive no hepatitis 2/5/05 determine if ANTI-HBS-reactive virus and the patient was HAV-IGM- non- was not expose to the reactive exposed to virus of if there any of it. is presence of hepatitis virus In the blood of the patient.

Nursing Responsibilities:

1. Explain the procedure to the patient

2. Tell the patient that no fasting is required 3. Apply pressure or a pressure dressing to the venipuncture site

12 4. Handle the specimen as if it were capable of transmitting hepatitis 5. Immediately discard the needle in the appropriate receptacle 6. Send the specimen to the laboratory promptly

Normal Date Indication AnalysisDiagnostic/ Values Ordered (s) andLaboratory Result used by Date Purpose InterpretatiProcedure the Result in (s) on hospital

1. Explain the procedure to the patient

162.Tell the patient that no fasting is required3. Apply pressure or a pressure dressing to the venipuncture site4. Assess the venipuncture site for bleeding

III. ANATOMY AND PHYSIOLOGY

Function of the Urinary System

The major functions of the urinary systems are performed by the kidneysand the kidneys plays the following essentials roles in controlling the compositionand volume of body fluids:1. Excretion. The kidneys are the major excretory organs of the body. They remove waste products, many of which are toxic, from the blood. Most waste products are metabolic by- products of cells and substances absorbed from the intestine. The skin, liver, lungs, and intestines eliminate some of these waste products, but they cannot compensate if the kidneys fail to function.2. Blood volume control. The kidneys play an essential role in controlling blood volume by regulating the volume of water removed from the blood to produce urine.3. Ion concentration regulation. The kidneys help regulate the concentration of the major ions in the body fluids.4. pH regulation. The kidneys help regulate the pH of the body fluids. Buffers in the blood and the respiratory system also play important roles in the regulation of pH5. Red blood cell concentration. The kidneys participate in the regulation of red blood cell production and therefore, in controlling the concentration of red blood cells in the blood.6. Vitamin D synthesis. The kidneys. Along with the skin and the liver, participate in the synthesis of vitamin D.

17Kidneys The kidneys balance the urinary excretion of substances against theaccumulation within the body through ingestion or production. Consequently,they are major controller of fluid and electrolyte homeostasis. The kidneys alsohave several non-excretory metabolic and endocrine functions, including bloodpressure regulation, erythropoietin production, insulin degradation, prostaglandinsynthesis, calcium and phosphorus regulation and Vitamin D metabolism. The kidneys are located retroperitoneally, in the posterior aspect of theabdomen. On either side of the ventral column. They lie between the 12 th thoracicand third lumbar vertebrae. The left kidney is usually positioned slightly higherthan the right. Adult kidneys are average approximately 11 cm in length, 5 to 7.5cm in width, and 2.5 cm in thickness. The kidney has a characteristic curvedshape, with a convex distal edge and a concave medial boundary.

Ureters, Urinary Bladder and Urethra

The ureters are small tubes that carry urine from the renal pelvis of thekidney to the posterior inferior portion of the urinary bladder. The urinary bladderis a hollow muscular container that lies in the pelvic cavity just posterior to thepubic symphysis. It functions to store urine, and its size depends on the quantityof urine present. The urinary bladder can hold from a few milliliters to a maximumof about 1000 mL of urine. When the urinary bladder reaches a volume of a fewhundred mL, a reflex is activated, which causes the smooth muscle of the urinarybladder to contract and most of the urine flows out of the urinary bladder throughurethra. The urethra is a tube that exits the urinary bladder inferiorly andanteriorly. The triangle-shaped portion of the urinary bladder located between theopening of the ureters and the opening of the urethra is called trigone. Theurethra carries urine from the urinary bladder to the outside of the body.Renal Blood flow and Glomerular Filtration The kidney receive 20% to 25% of the cardiac output under restingconditions, averaging more than 1 L of arterial blood per minute. The renalarteries branch from the abdominal aorta at the level of he second lumbar

18vertebra, enter the kidney, and progressively branch into lobar arteries. Bloodflows from the interlobular arteries through the afferent arteriole, the glomerularcapillaries, the efferent arteriole and the peritubular capillaries. Some of theperitubular capillaries carry a small amount of blood to the renal medulla in thevasa recta before entering the venous drainage. The blood leaves the kidney invenous system closely corresponding to the arterial system: interlobular veins,arcuate veins, interlobar veins, and the renal vein. The renal circulation thenempties into the inferior vena cava.

PhysiologyCharacteristics of Urine Urine is a watery solution of nitrogenous waste an inorganic salts that areremoved from the plasma and eliminated by the kidneys. It is 5% water and 5%dissolved solids and gases. The amount of these dissolved substances isindicated by it specific gravity. The specific gravity of pure water, used as astandard is 1.000. Because of the dissolved materials it contains, urine has aspecific gravity that normally varies from 1.010 to 1.040. When the kidneys arediseased, they lose the ability to concentrate urine, and the specific gravity nolonger varies as it does when the kidneys function normally.Urine formation The chief function of the kidneys is to produce urine. Each part of thenephrons performs a special function. There are three important processes bywhich urine is formed. They are glomerular filtration, tubular reabsorption andtubular secretion

The path of the Formation of Urine

Passes To Bowman’s Now it becomes

To the To the distal

collecting To the loop of Continues through thetubuleconvulated tubule (at this about proximal 19 convulated Henle 1 ml of Approximately The 1 ml of urine To the 99% urinary of the filtrate urine is formed per goestubule to the renal meatus has been To the To the To the minute pelvis urethra bladder ureterFluid and Electrolyte BalanceElectrolyte Balance Electrolytes are important constituents of body fluids. These arecompounds that separate into positively and negatively charged ions and carryan electric current in solution. The main source of electrolytes is food. A few ofthe most important ions are considered here.1. Sodium- chiefly responsible for maintaining osmotic balance and body fluid volume. It is the main positive in extracellular fluids. Sodium is required for nerve impulse conduction and is important in maintaining acid-base balance.2. Potassium- important in the transmission of nerve impulse; a major positive ion in the intracellular fluids. It is involved in cellular enzyme activities and helps regulate the chemical reactions by which carbohydrate is converted to protein.3. Calcium-required for bone formation, muscle contraction, nerve impulse transmission, and blood clotting4. Phosphate- essential in the metabolism of carbohydrates, bone formation and acid-base balance. They are found in the cell membrane and in the nucleic acids.5. Chloride- essential for formation of the hydrochloric acid of the gastric juice.

20 Electrolytes must be kept in the proper concentration in both intracellular andextracellular fluids. Although some electrolytes are lost in the feces and throughthe skin as sweat, the job of balancing electrolytes is left mainly to the kidneys. There are several hormones that are involved in this process. Aldosteroneproduced by the adrenal cortex promotes the reabsorption of sodium and theelimination of potassium. Hormones from parathyroid and thyroid glands regulatecalcium and phosphate levels. Parathyroid hormones increases blood calcium,levels by causing the bones to release calcium and by causing the kidneys toreabsorb calcium. The thyroid hormone calcitonin lowers blood calcium bycausing calcium to be deposited in the bone.

IV. THE PATIENT AND HIS ILLNESS

SYNTHESIS OF THE DISEASE (CLIENT CENTERED)

Chronic Renal Failure

Chronic or irreversible, renal failure is a progressive reduction of

functioning renal tissue such that the remaining kidney mass can no longermaintain the body’s internal environment. Chronic Renal failure can developinsidiously over many years, or it may result from an episode of acute renalfailure from which the client has not recovered.

Precipitating Factors Chronic glomerular disease such as glomerunephritis Chronic infections such as chronic pyelonephritis or tuberculosis Congenital anomalities such as polycystic Vascular diseases, such as renal nephrosclerosis or hypertension Obstructive processes such as calculi Collagen diseases such as systemic lupus erythematosus nephrotoxic agents such as long-term aminoglycoside endocrine diseases such as diabetic neuropathy

Predisposing Factors Sex- both sexes are affected by chronic renal failure. But in 1998, based on United States Renal Data System, a higher total number of males with ESRD was found Age- CRF can be found in people of any age, from infants to the very old. The elderly population also is the most rapidly growing ESRD population in the United States. Note that age 30 years progressive physiological glomerulosclerosis. Aging also results in concomitant progressive physiological decrease in muscle mass such that daily urinary creatinine excretion also decreases.

Clinical Manifestations The clinical manifestations of CRF are present throughout the body. Noorgan system is spared. Electrolyte imbalances Electrolyte balance may be upset by impaired excretion and utilization in the kidney. Although many clients maintain normal serum sodium level, the salt-wasting properties of some failing kidneys, in addition to vomiting and diarrhea, may cause hyponatremia. Because the kidneys are efficient at excreting potassium, potassium levels usually remain within normal limits until late in the disease. Several mechanisms contriburte to hypocalcemia. Conversion of 25-hydroxycholecalciferol to 1,25-dihyroxycholecalciferol (necessary to absorb calcium) is decreased, which results in reduced intestinal absorption of calcium. At the same time, phosphate is not excreted, which causes hyperphosphatemia. Because calcium and phosphate are

22 inversely related, a high phosphate level results in a reduced calcium level. Metabolic changes In advancing renal failure, BUN and serum creatinine rise as waste products of protein metabolism accumulate in the blood. The serum creatinine level is the most accurate measure of renal function. The proteinuria accompanying renal disease and sometimes inadequate dietary intake of proteins cause hypoproteinuria, which lowers the intravascular oncotic pressure. Metabolic acidosis occurs because of the kidney’s inability to excrete hydrogen ions. Decrease reabsorption of sodium bicarbonate and decreased formation of dihydrogen phosphate and ammonia contribute to this problem. Acidosis accentuates hyperkalemia and the reabsorption of calcium from the bones. Hematologic changes The primary hematologic effect of renal failure is anemia, usually normochromic and normocytic. It occurs because the kidneys are unable to produce erythropoietin, a hormone necessary for red blood cell production. Frequently, the fatigue, weakness, and cold intolerance accompanying the anemia lead to a diagnosis of renal failure. Gastrointestinal changes The entire gastrointestinal system is affected. Transient anorexia, nausea, vomiting are almost universal. Clients often experience a constant bitter , metallic, or salty taste, and their breath commonly smells fetid, fishy or ammonia-like. Stomatitis, parotitis and gingivitis are common problems because of poor oral hygiene and the formation of ammonia from salivary urea. Accumulations of gastro may be a major cause of ulcer disease. Esophagitis, gastritis, colitis, gastrointestinal bleeding, and diarrhea may be present. Serum amylase level may be increased, although they do not necessarily indicate pancreatitis. Immunologic changes

23 Impairment of the immune system makes the client more susceptible to infection. Several factors are involved, including depression of humoral antibody formation, suppression of delayed hypersensitivity and decreased chemotactic function of leukocytes. Immunosuppression is an important part of the medical management of renal diseaes such as glomerulonephritis. Cardiovascular changes The most common clinical manifestation is hypertension, producedthrough: mechanism of volume overload, stimulation of the renin-angiotensin system, sympatheically mediated vasoconstriction, absence of prostaglandins. Respiratory changes Some of the respiratory effects such as pulmonary edema can be attributed to fluid overload. Metabolic acidosis causes a compensatory increase in respiratory rate as the lungs try to eliminate excess hydrogen ions. Musculoskeletal changes The etiologic mechanism involves the kidney-bone-parathyroid and calcium-phosphate-vitamin D connections. As the GRF decreases, the phosphate excretion decreases and calcium elimination increases. Abnormal levels of calcium and phosphate stimulate the release of parathyroid hormone that mobilizes calcium from the bones and facilitates phosphate excretion. Integumentary changes The skin is also often very dry because of atrophy of the sweat glands. Severe and intractable pruritus may result from secondary hyperparathyroidism and calcium deposits in the skin. The pallor of anemia is evident.

V. The Patient and his Care

1. D5 LRS iL x Ordered: To Patient felt Patient

KVO 2/3,7,9/05 maintain discomfort fluid status Performed: fluid was 2/3,7,9/05 balance of maintained Changed: the pt. 2/3/05 D/C 2/10/052. D5 NaCl iL xKVO Ordered: A 2/3/05 crystallized Patient Performed: solution To fluid status 2/3/05 that is maintain was available in fluid maintained a variety of balance of concentrat the pt. ed water and calories are provided. It is hypertonic3. Ordered: solution PatientSubclavian 2/7/05 containing experiencecatheteriz Performed: equal d bleedingation 2/7/05 amounts of and felt Na and Cl discomfort Patient did on incision not show A catheter site any further tube is bleeding inserted Temporary into vein in access for either your hemodialy Ordered: neck, sis 2/3/05 chest, leg4.Blood or near the During theTransfusi Performed: groin. It bloodon 2/3/05 has two transfusion chambers , patient Patient did to allow was manifest

25 two-way chilling for some flow of a short reaction blood To period of such as immediatel time. chilling but It is y restore There was there was intravenou blood no further not further s volume to adverse reaction replaceme treat reaction after the Ordered: nt of loss severe noted upon treatment 2/7,8,9/05 or anemia, to the5. destroyed be able to transfusionHemodial Performed: blood maintain ysi 2/7,8,10/0 compatible oxygen s 5 citrated transport human to the Patient blood it is different was also the parts of slightly There was introductio the body nervous no adverse n of whole about the reaction blood or treatment noted blood . during and Componen after the t procedure It is indicated for the Medical patient treatment because used to the promote kidneys excretion cannot of wastes function materials very well from the to excrete blood of the patient. nitrogenou s waste products, thus leading to its accumulati on in the blood.

Nursing Responsibilities

261. Blood transfusion Before a. Assess client for history of previous BT and any adverse reactions b. Ensure that the client has an 18 to 19 gauge IV catheter in place c. Use 0.9% sodium chloride IVF d. Verify the ABO group, Rh type, client and blood numbers and expiration date. e. Take baseline vital signs before initiating BT f. Identify the patient prior to transfusion g. Explain the purpose of the transfusion

27 a. Obtain and record vital signs before and every 30 mins. during the procedure b. Ensure bedrest with frequent position changes for comfort c. Proper heparinization must be done to prevent coagulation during the therapy d. Inform client that headache and nausea may occur e. Monitor closely for bleeding since blood has been heparinized for procedure After a. Weight the patient after the therapy and record b. Monitor vital signs especially hypotension. c. Assess for complications (hypovolemic shock, dialysis disequilibrium syndrome) Date ordered Route of Client’s Date admin. Indication Name of General response Taken Dosage (s) Drug action to Date and freq. Purpose(s) medication changed or Of admin. D/C

Date ordered Client’s

DAT Ordered: Any foods To provide Patient

2/3/05 and fluids nutrients followed the Started: that are needed by diet 2/3/05 being the body Changed: tolerated by 2/3/05 the patient

Low salt, Ordered:

low protein 2/3/05 To decrease Patient Started: Foods that further strictly 2/3-10/05 has low salt production of complied with and protein purine which the value can prescribed contribute in diet increasing level of creatinine in the blood

Nursing Responsibilities

Prior: 1. Check and determine the prescribed diet 2. Inform the SO about the prescribed diet 3. Explain the procedure and purpose of the prescribed diet 4. Cite foods that are restricted.

Date ordered Client’s

Bed rest Ordered: An activity To decrease Patient

2/3/05 wherein the consumption strictly Started: patient is not of oxygen complied with 2/3-10/05 allowed to do and to be the any activity. able to prescribed Patient stays conserve activity at bed. energy

Nursing Responsibilities

1. Explain the procedure to patient.

An AV fistula requires advance planning because a fistula takes a while

after surgery to develop (in rare cases, as long as 24 months). But a properlyformed fistula is less likely than other kinds of vascular accesses to form clots orbecome infected. Also, fistulas tend to last many years, longer than any otherkind of vascular access.

31 A surgeon creates an AV fistula by connecting an artery directly to a vein,usually in the forearm. Connecting the artery to the vein causes more blood flowinto the vein. As a result, the vein grows larger and stronger, making repeatedinsertions for hemodialysis treatment easier. For the surgery, you will be given alocal anesthetic. In most cases, the procedure can be performed on an outpatientbasis.

These fistulas require up to 6 weeks to mature before they can be used,

which makes this approach inappropriate for immediate hemodialysis. Peritonealdialysis or large venous access catheters may be used while the fistula ismaturing. External arteriovenous shunts are rarely used.

Nursing management

Actual SOAPIE

February 3, 2005

S> “madali akong mapagod”

O> received patient on semi-fowler’s position, with an ongoing IVF of D5 NM 1 L

B. Discharge Planning Mr. x was discharge last x, Upon discharged, Mr. x’s physical appearancewas improved. There was absence of paleness in the conjunctiva and lips,fatigability is decrease, and with decrease creatinine level as compared when hewas admitted in the hospital. His vital signs were as follows: T- 36.5, PR- 85, RR-18, BP- 140/100.

M> Instructed to complied strictly with the following home medications

VII. Conclusion and Recommendations

Chronic renal failure is an irreversible and progressive disease. It is cause

by many factors. Knowing the precipitating factors leading to the development ofthis health problem, people should have an extra care when it comes to health.

Giving care to a patient whether pediatric, geriatric, a medical case or

surgical case makes no difference. Rendering care to everyone who needs it is areal sense of responsibility. In making this case study, I was able to work wellbecause I know for myself that I did my best for my patient.

We can say that nursing is significant therapeutic and dynamic process. It

is therefore significant for the nurse caring for the patient to wholeheartedlyunderstand what she is doing like in carrying out some basic skills in relation toidentified goals, comfort and care, interventions and prevention of illness.